{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T14:50:15Z","timestamp":1787755815967,"version":"build-2784847793"},"reference-count":46,"publisher":"Oxford University Press (OUP)","issue":"1","license":[{"start":{"date-parts":[[2025,12,1]],"date-time":"2025-12-01T00:00:00Z","timestamp":1764547200000},"content-version":"vor","delay-in-days":15,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Academy of Medical Sciences starter"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,11,16]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Aim<\/jats:title>\n                    <jats:p>To understand the views and experiences of homeless adults who drink hazardously around alcohol use, alcohol harms and access to liver healthcare, and to quantify the prevalence of alcohol-related morbidity in this population.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A sample of homeless adults (aged 18+) who drink hazardously (AUDIT score\u2009\u22658) were recruited to complete a health and alcohol use survey. From this sample, a smaller sample was purposively selected for semi-structured interview. Participants were recruited via liver outreach clinics held in five homeless hostels\/day-centres in Southampton. Using a critical realist approach, qualitative data were analyzed using reflexive thematic analysis and descriptive statistics produced for survey responses.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Around 56 survey participants were recruited, 84% of whom had probable alcohol dependence and 18% a diagnosis of advanced liver fibrosis\/cirrhosis. Themes identified from 10 interviews described the ubiquity of alcohol misuse and harms in the life-histories of people experiencing homelessness (PEH), the differing levels of understanding and risk recognition of alcohol-related harms, and how PEH rationalize hazardous drinking, despite the risks. Normalization of alcohol misuse and harms underlies these themes and likely contributes to feelings of fatalism and powerlessness to prevent these harms.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Normalization of alcohol-related harms may represent a barrier to timely engagement with healthcare and a mechanism driving greater likelihood of alcohol-related harms in PEH. Improving knowledge around alcohol-related harms and healthcare may help to counter the misperceptions of risk and fatalistic attitudes that normalization fosters. Such intervention may be particularly effective for PEH if targeted towards those accessing hostels and day-centres.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/alcalc\/agaf071","type":"journal-article","created":{"date-parts":[[2025,10,28]],"date-time":"2025-10-28T12:52:26Z","timestamp":1761655946000},"source":"Crossref","is-referenced-by-count":1,"title":["Normalization of alcohol misuse and alcohol-related harms: a mixed methods analysis exploring alcohol misuse, morbidity, and healthcare engagement in people experiencing homelessness"],"prefix":"10.1093","volume":"61","author":[{"given":"Catherine","family":"Wells","sequence":"first","affiliation":[{"name":"Primary Care, Population Sciences and Medical Education, Faculty of Medicine, Tremona Road, University of Southampton , Southampton , SO16 6YD,","place":["United Kingdom"]},{"name":"Public Health and Social Research Unit, West Sussex County Council , West Street, Chichester , PO19 1RG,","place":["United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rachel","family":"Dewar-Haggart","sequence":"additional","affiliation":[{"name":"Primary Care, Population Sciences and Medical Education, Faculty of Medicine, Tremona Road, University of Southampton , Southampton , SO16 6YD,","place":["United Kingdom"]},{"name":"Nuffield Department of Primary Care Health Sciences, University of Oxford , Woodstock Road, Oxford , OX2 6GG,","place":["United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kate","family":"Glyn-Owen","sequence":"additional","affiliation":[{"name":"Primary Care, Population Sciences and Medical Education, Faculty of Medicine, Tremona Road, University of Southampton , Southampton , SO16 6YD,","place":["United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hannah","family":"Stevens","sequence":"additional","affiliation":[{"name":"University Hospital Southampton , Tremona Road, Southampton , SO16 6YD,","place":["United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julie","family":"Parkes","sequence":"additional","affiliation":[{"name":"Primary Care, Population Sciences and Medical Education, Faculty of Medicine, Tremona Road, University of Southampton , Southampton , SO16 6YD,","place":["United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yun","family":"Kim","sequence":"additional","affiliation":[{"name":"Primary Care, Population Sciences and Medical Education, Faculty of Medicine, Tremona Road, University of Southampton , Southampton , SO16 6YD,","place":["United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ryan M","family":"Buchanan","sequence":"additional","affiliation":[{"name":"Primary Care, Population Sciences and Medical Education, Faculty of Medicine, Tremona Road, University of Southampton , Southampton , SO16 6YD,","place":["United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2025,12,1]]},"reference":[{"key":"2026021600120030500_ref1","doi-asserted-by":"publisher","first-page":"241","DOI":"10.1016\/S0140-6736(17)31869-X","article-title":"Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: A systematic review and meta-analysis","volume":"391","author":"Aldridge","year":"2018","journal-title":"Lancet"},{"key":"2026021600120030500_ref2","doi-asserted-by":"publisher","first-page":"49","DOI":"10.12688\/wellcomeopenres.15151.1","article-title":"Causes of death among homeless people: A population-based cross-sectional study of linked hospitalisation and mortality data in England","volume":"4","author":"Aldridge","year":"2019","journal-title":"Wellcome Open Res"},{"key":"2026021600120030500_ref3","volume-title":"AUDIT: The Alcohol Use Disorders Identification Test. Guidelines for Use in Primary Care","author":"Babor","year":"2001","edition":"Second"},{"key":"2026021600120030500_ref4","doi-asserted-by":"crossref","first-page":"e515","DOI":"10.3399\/bjgp19X704609","article-title":"Multimorbidity and emergency department visits by a homeless population: A database study in specialist general practice","volume":"69","author":"Bowen","year":"2019","journal-title":"Br J Gen Pract"},{"key":"2026021600120030500_ref5","doi-asserted-by":"publisher","first-page":"77","DOI":"10.1191\/1478088706qp063oa","article-title":"Using thematic analysis in psychology","volume":"3","author":"Braun","year":"2006","journal-title":"Qual Res Psychol"},{"key":"2026021600120030500_ref6","doi-asserted-by":"publisher","first-page":"373","DOI":"10.1016\/0021-9681(87)90171-8","article-title":"A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation","volume":"40","author":"Charlson","year":"1987","journal-title":"J Chronic Dis"},{"key":"2026021600120030500_ref7","volume-title":"Childhood Vulnerability in England 2019: Vulnerable Groups and Latest Data","author":"Children\u2019s Commissioner for England","year":"2019"},{"key":"2026021600120030500_ref8","volume-title":"Designing and Conducting Mixed Methods Research","author":"Creswell","year":"2017"},{"key":"2026021600120030500_ref9","volume-title":"Evaluation of the Children of Alcohol Dependent Parents Programme Innovation Fund: Full Report","author":"Department of Health & Social Care","year":"2023"},{"key":"2026021600120030500_ref10","doi-asserted-by":"publisher","first-page":"26","DOI":"10.1093\/pubmed\/fdw008","article-title":"Factors associated with access to care and healthcare utilization in the homeless population of England","volume":"39","author":"Elwell-Sutton","year":"2017","journal-title":"J Public Health"},{"key":"2026021600120030500_ref11","volume-title":"ETHOS European Typology on Homelessness and Housing Exclusion","author":"European Federation of National Organizations Working with the Homeless","year":"2017"},{"key":"2026021600120030500_ref12","doi-asserted-by":"publisher","first-page":"1529","DOI":"10.1016\/S0140-6736(14)61132-6","article-title":"The health of homeless people in high-income countries: Descriptive epidemiology, health consequences, and clinical and policy recommendations","volume":"384","author":"Fazel","year":"2014","journal-title":"Lancet"},{"key":"2026021600120030500_ref13","doi-asserted-by":"publisher","first-page":"857","DOI":"10.1186\/s12913-019-4620-1","article-title":"Secondary care usage and characteristics of hospital inpatients referred to a UK homeless health team: A retrospective service evaluation","volume":"19","author":"Field","year":"2019","journal-title":"BMC Health Serv Res"},{"key":"2026021600120030500_ref14","doi-asserted-by":"publisher","first-page":"492","DOI":"10.1111\/j.1365-2524.2010.00925.x","article-title":"Selling your self? The psychological impact of street sex work and factors affecting support seeking","volume":"18","author":"Gorry","year":"2010","journal-title":"Health Soc Care Community"},{"key":"2026021600120030500_ref15","doi-asserted-by":"publisher","first-page":"1028","DOI":"10.1111\/j.1467-9566.2009.01172.x","article-title":"Troubling biographical disruption: Narratives of unconcern about hepatitis C diagnosis","volume":"31","author":"Harris","year":"2009","journal-title":"Sociol Health Illn"},{"key":"2026021600120030500_ref16","doi-asserted-by":"publisher","first-page":"628","DOI":"10.1111\/liv.15122","article-title":"Chronic liver disease in homeless individuals and performance of non-invasive liver fibrosis and injury markers: VALID study","volume":"42","author":"Hashim","year":"2022","journal-title":"Liver Int"},{"key":"2026021600120030500_ref17","doi-asserted-by":"publisher","DOI":"10.58248\/PN570","volume-title":"Parental Alcohol Misuse and Children","author":"Hedges","year":"2018"},{"key":"2026021600120030500_ref18","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1002\/9781119410867.ch4","volume-title":"Qualitative Research in Health Care","author":"Hinton","year":"2020","edition":"4th"},{"key":"2026021600120030500_ref19","doi-asserted-by":"publisher","first-page":"204","DOI":"10.1016\/j.drugpo.2013.11.004","article-title":"Views and experiences of hepatitis C testing and diagnosis among people who inject drugs: Systematic review of qualitative research","volume":"25","author":"Jones","year":"2014","journal-title":"Int J Drug Policy"},{"key":"2026021600120030500_ref20","doi-asserted-by":"publisher","first-page":"61","DOI":"10.1016\/S0140-6736(21)01701-3","article-title":"The EASL-lancet liver commission: Protecting the next generation of Europeans against liver disease complications and premature mortality","volume":"399","author":"Karlsen","year":"2022","journal-title":"Lancet"},{"key":"2026021600120030500_ref21","doi-asserted-by":"publisher","first-page":"69","DOI":"10.5153\/sro.2540","article-title":"Socio-cultural risk? Reporting on a qualitative study with female street-based sex workers","volume":"16","author":"Leaker","year":"2011","journal-title":"Sociol Res Online"},{"key":"2026021600120030500_ref22","doi-asserted-by":"publisher","first-page":"e025192","DOI":"10.1136\/bmjopen-2018-025192","article-title":"Health-related quality of life and prevalence of six chronic diseases in homeless and housed people: A cross-sectional study in London and Birmingham, England","volume":"9","author":"Lewer","year":"2019","journal-title":"BMJ Open"},{"key":"2026021600120030500_ref23","doi-asserted-by":"publisher","first-page":"681","DOI":"10.1136\/jech-2020-215204","article-title":"Hospital readmission among people experiencing homelessness in England: A cohort study of 2772 matched homeless and housed inpatients","volume":"75","author":"Lewer","year":"2021","journal-title":"J Epidemiol Community Health"},{"key":"2026021600120030500_ref24","doi-asserted-by":"publisher","first-page":"474","DOI":"10.3109\/10826084.2012.644097","article-title":"A social network approach to demonstrate the diffusion and change process of intervention from peer health advocates to the drug using community","volume":"47","author":"Li","year":"2012","journal-title":"Subst Use Misuse"},{"key":"2026021600120030500_ref25","doi-asserted-by":"publisher","first-page":"e836","DOI":"10.1016\/S2468-2667(21)00189-4","article-title":"Adverse childhood experiences and related outcomes among adults experiencing homelessness: A systematic review and meta-analysis","volume":"6","author":"Liu","year":"2021","journal-title":"Lancet Public Health"},{"key":"2026021600120030500_ref26","doi-asserted-by":"publisher","first-page":"266","DOI":"10.1016\/S0140-6736(17)31959-1","article-title":"What works in inclusion health: Overview of effective interventions for marginalised and excluded populations","volume":"391","author":"Luchenski","year":"2018","journal-title":"Lancet"},{"key":"2026021600120030500_ref27","doi-asserted-by":"publisher","first-page":"150","DOI":"10.1186\/s12939-017-0646-3","article-title":"Social conditions of becoming homelessness: Qualitative analysis of life stories of homeless peoples","volume":"16","author":"Mabhala","year":"2017","journal-title":"Int J Equity Health"},{"key":"2026021600120030500_ref28","doi-asserted-by":"publisher","first-page":"1753","DOI":"10.1177\/1049732315617444","article-title":"Sample size in qualitative interview studies: Guided by information power","volume":"26","author":"Malterud","year":"2015","journal-title":"Qual Health Res"},{"key":"2026021600120030500_ref29","doi-asserted-by":"publisher","first-page":"287","DOI":"10.1093\/pubmed\/fdz104","article-title":"Homeless people and health: A qualitative enquiry into their practices and perceptions","volume":"43","author":"Mc Conalogue","year":"2021","journal-title":"J Public Health"},{"key":"2026021600120030500_ref30","doi-asserted-by":"publisher","first-page":"910","DOI":"10.1186\/s12913-022-08265-y","article-title":"Access to healthcare for people experiencing homelessness in the UK and Ireland: A scoping review","volume":"22","author":"McNeill","year":"2022","journal-title":"BMC Health Serv Res"},{"key":"2026021600120030500_ref31","doi-asserted-by":"publisher","first-page":"415","DOI":"10.1146\/annurev.soc.27.1.415","article-title":"Birds of a feather: Homophily in social networks","volume":"27","author":"McPherson","year":"2001","journal-title":"Annu Rev Sociol"},{"key":"2026021600120030500_ref32","doi-asserted-by":"publisher","first-page":"1016","DOI":"10.1186\/s12889-018-5948-x","article-title":"Constructions of alcohol consumption by non-problematised middle-aged drinkers: A qualitative systematic review","volume":"18","author":"Muhlack","year":"2018","journal-title":"BMC Public Health"},{"key":"2026021600120030500_ref33","doi-asserted-by":"publisher","first-page":"1245","DOI":"10.1097\/acm.0000000000000388","article-title":"Standards for reporting qualitative research: A synthesis of recommendations","volume":"89","author":"O'Brien","year":"2014","journal-title":"Acad Med"},{"key":"2026021600120030500_ref34","doi-asserted-by":"publisher","first-page":"113","DOI":"10.1186\/s12939-019-1002-6","article-title":"Making sense of street chaos: An ethnographic exploration of homeless people's health service utilization","volume":"18","author":"O'Carroll","year":"2019","journal-title":"Int J Equity Health"},{"key":"2026021600120030500_ref35","volume-title":"Alcohol-Specific Deaths in the UK: Registered in 2020 [Online]","year":"2021"},{"key":"2026021600120030500_ref36","volume-title":"Deaths of Homeless People in England and Wales: 2021 Registrations [Online]","year":"2022"},{"key":"2026021600120030500_ref37","doi-asserted-by":"publisher","first-page":"48","DOI":"10.1111\/hex.13400","article-title":"Barriers and facilitators to hepatitis C screening and treatment for people with lived experience of homelessness: A mixed-methods systematic review","volume":"25","author":"Paisi","year":"2022","journal-title":"Health Expect"},{"key":"2026021600120030500_ref38","volume-title":"Realistic Evaluation","author":"Pawson","year":"1997"},{"key":"2026021600120030500_ref39","doi-asserted-by":"crossref","first-page":"15","DOI":"10.1002\/9781119410867.ch2","volume-title":"Qualitative Research in Health Care","author":"Pope","year":"2020"},{"key":"2026021600120030500_ref40","doi-asserted-by":"publisher","first-page":"426","DOI":"10.7326\/0003-4819-152-7-201004060-00007","article-title":"The spread of alcohol consumption behavior in a large social network","volume":"152","author":"Rosenquist","year":"2010","journal-title":"Ann Intern Med"},{"key":"2026021600120030500_ref41","doi-asserted-by":"publisher","first-page":"204","DOI":"10.1111\/add.13097","article-title":"Does parental drinking influence children's drinking? A systematic review of prospective cohort studies","volume":"111","author":"Rossow","year":"2016","journal-title":"Addiction"},{"key":"2026021600120030500_ref42","doi-asserted-by":"publisher","first-page":"246","DOI":"10.1016\/j.drugalcdep.2018.06.013","article-title":"\u2018Hep C\u2019s like the common cold\u2019: Understanding barriers along the HCV care continuum among young people who inject drugs","volume":"190","author":"Skeer","year":"2018","journal-title":"Drug Alcohol Depend"},{"key":"2026021600120030500_ref43","doi-asserted-by":"publisher","first-page":"94","DOI":"10.1017\/jsc.2020.11","article-title":"Smoking amongst adults experiencing homelessness: A systematic review of prevalence rates, interventions and the barriers and facilitators to quitting and staying quit","volume":"15","author":"Soar","year":"2020","journal-title":"J Smok Cess"},{"key":"2026021600120030500_ref44","doi-asserted-by":"publisher","first-page":"16","DOI":"10.1016\/j.drugalcdep.2009.05.026","article-title":"The social context of homeless women's alcohol and drug use","volume":"105","author":"Wenzel","year":"2009","journal-title":"Drug Alcohol Depend"},{"key":"2026021600120030500_ref45","doi-asserted-by":"publisher","first-page":"226","DOI":"10.1016\/S0140-6736(19)32908-3","article-title":"Unacceptable failures: The final report of the lancet commission into liver disease in the UK","volume":"395","author":"Williams","year":"2020","journal-title":"Lancet"},{"key":"2026021600120030500_ref46","doi-asserted-by":"publisher","first-page":"388","DOI":"10.1016\/j.drugpo.2007.02.006","article-title":"Everybody's got it, but\u2026: Situational and strategic participation in normalized HCV discourse among injection drug users in Edmonton, Canada","volume":"18","author":"Wozniak","year":"2007","journal-title":"Int J Drug Policy"}],"container-title":["Alcohol and Alcoholism"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/alcalc\/article-pdf\/61\/1\/agaf071\/65665935\/agaf071.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/alcalc\/article-pdf\/61\/1\/agaf071\/65665935\/agaf071.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,16]],"date-time":"2026-02-16T05:12:07Z","timestamp":1771218727000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/alcalc\/article\/doi\/10.1093\/alcalc\/agaf071\/8362136"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,11,16]]},"references-count":46,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2025,11,16]]}},"URL":"https:\/\/doi.org\/10.1093\/alcalc\/agaf071","relation":{},"ISSN":["0735-0414","1464-3502"],"issn-type":[{"value":"0735-0414","type":"print"},{"value":"1464-3502","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2026,1]]},"published":{"date-parts":[[2025,11,16]]},"article-number":"agaf071"}}